[Recipient Name]
[Date]
Page 1
[Your Name]
[Title]
[Institution]
[Street Address]
[City, ST ZIP Code]
[Date]
R. Serene Perkins, MD, FACS
Director of Clinical Research and Program Director, Legacy Tumor Bank
Legacy Research Institute
1225 NE 2nd Ave.
Portland, OR 97232
Re: "[Working Title of Research Project]"
Dear Dr. Perkins:
This letter is written to request a waiver of patient authorization in order to facilitate the access to tumor samples in the LegacyTumor Bank in support of our research project“[Working Title of Research Project]”. We would like permission to use,if available,XX samples of XX tumors, and matched control tissue samples. Corresponding anonymizeddata points in the attached data request form are also requested.
In requesting this authorization I have determined that this study could not be practicably done without it, and that this release of tissue and data poses no more than minimal risk to the privacy of the patient. The tissue and data requested are the minimum necessary required to accomplish the goals of this study. In working with the provided samples and data, I will abide by all applicable federal, state and locals rules and laws pertaining to research conduct. In addition, I will communicate any concern about research misconduct, quality or safety related to acquisition or use of Legacy Tumor Bank specimens and data to the appropriate governing body.In extracting data from the samples I will not be recording information that could directly identify the patient.I will have no access to Protected Health Information (PHI) in association with these samples. I will not be contacting the patients whose tissues I am reviewing, and neither their names, nor any personal identifiers will appear in any publication resulting from this work. I will not be sharing this data with others outside of this research project except in aggregate form in future scientific publications.
If there are unused samples at the end of our study, our plan for them is to [return the samples to Legacy Tumor Bank or destroy the samples].
In receiving this tissue, I agree to acknowledge the Legacy Tumor Bank in any publication that may arise from our work. The Legacy Tumor Bank will be acknowledged in publications as follows:
Individual acknowledgements:
R. Serene Perkins, MD, FACS, Director of Clinical Research, Legacy Research Institute
John Ost, Research Assistant, Legacy Tumor Bank
In receiving this tissue, I agree to provide data on the use of the samples provided, including any resulting abstracts, presentations and publications, to the director of the Legacy Tumor Bank annually or on reasonable request.
Sincerely,
[Your Name]
[Title]